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How to Fix Bad Ankles

By Gretchen Reynolds July 8, 2009 10:30 amJuly 8, 2009 10:30 am

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Ankles provide a rare opportunity to recreate a seminal medical study in the comfort of your own home. Back in the mid-1960s, a physician, wondering why, after one ankle sprain, his patients so often suffered another, asked the affected patients to stand on their injured leg (after it was no longer sore). Almost invariably, they wobbled badly, flailing out with their arms and having to put their foot down much sooner than people who’d never sprained an ankle. With this simple experiment, the doctor made a critical, if in retrospect, seemingly self-evident discovery. People with bad ankles have bad balance.

Remarkably, that conclusion, published more than 40 years ago, is only now making its way into the treatment of chronically unstable ankles. “I’m not really sure why it’s taken so long,” says Patrick McKeon, an assistant professor in the Division of Athletic Training at the University of Kentucky. “Maybe because ankles don’t get much respect or research money. They’re the neglected stepchild of body parts.”

At the same time, in sports they’re the most commonly injured body part — each year approximately eight million people sprain an ankle. Millions of those will then go on to sprain that same ankle, or their other ankle, in the future. “The recurrence rate for ankle sprains is at least 30 percent,” McKeon says, “and depending on what numbers you use, it may be high as 80 percent.”

A growing body of research suggests that many of those second (and often third and fourth) sprains could be avoided with an easy course of treatment. Stand on one leg. Try not to wobble. Hold for a minute. Repeat.

Video

Ankles: A Balancing Act

Ankles sprains are the most common injury for physically active people. Professor Jay Hertel of the University of Virginia demonstrates four balancing exercises to strengthen ankles.

This is the essence of balance training, a supremely low-tech but increasingly well-documented approach to dealing with unstable ankles. A number of studies published since last year have shown that the treatment, simple as it is, can be quite beneficial.

In one of the best-controlled studies to date, 31 young adults with a history of multiple ankle sprains completed four weeks of supervised balance training. So did a control group with healthy ankles. The injured started out much shakier than the controls during the exercises. But by the end of the month, those with wobbly ankles had improved dramatically on all measures of balance. They also reported, subjectively, that their ankles felt much less likely to give way at any moment. The control group had improved their balance, too, but only slightly. Similarly, a major review published last year found that six weeks of balance training, begun soon after a first ankle sprain, substantially reduced the risk of a recurrence. The training also lessened, at least somewhat, the chances of suffering a first sprain at all.

Why should balance training prevent ankle sprains? The reasons are both obvious and quite subtle. Until recently, clinicians thought that ankle sprains were primarily a matter of overstretched, traumatized ligaments. Tape or brace the joint, relieve pressure on the sore tissue, and a person should heal fully, they thought. But that approach ignored the role of the central nervous system, which is intimately tied in to every joint. “There are neural receptors in ligaments,” says Jay Hertel, an associate professor of kinesiology at the University of Virginia and an expert on the ankle. When you damage the ligament, “you damage the neuro-receptors as well. Your brain no longer receives reliable signals” from the ankle about how your ankle and foot are positioned in relation to the ground. Your proprioception — your sense of your body’s position in space — is impaired. You’re less stable and more prone to falling over and re-injuring yourself.

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For some people, that wobbliness, virtually inevitable for at least a month after an initial ankle sprain, eventually dissipates; for others it’s abiding, perhaps even permanent. Researchers don’t yet know why some people don’t recover. But they do believe that balance training can return the joint and its neuro-receptor function almost to normal.

Best of all, if you don’t mind your spouse sniggering, you can implement state-of-the-art balance training at home. “We have lots of equipment here in our lab” for patients to test, stress, and improve their balance, Hertel says. “But all you really need is some space, a table or wall nearby to steady yourself if needed, and a pillow.” (If you’ve recently sprained your ankle, wait until you comfortably can bear weight on the joint before starting balance training.) Begin by testing the limits of your equilibrium. If you can stand sturdily on one leg for a minute, cross your arms over your chest. If even that’s undemanding, close your eyes. Hop. Or attempt all of these exercises on the pillow, so that the surface beneath you is unstable. “One of the take-home exercises we give people is to stand on one leg while brushing your teeth, and to close your eyes if it’s too easy,” Hertel says. “It may sound ridiculous, but if you do that for two or three minutes a day, you’re working your balance really well.”

Actually, the loss of proprioception after an ankle sprain isn’t just making itself known in medical circles now at all. It’s been around at least since I was a resident in the early 1990’s. We always send our grade II ankle sprains (and even some grade I’s) to physical therapy for a quick course in balance training to restore proprioception. The challenge is that it can take months, or even up to a year, for a severe ankle sprain to heal completely (not that you have to wait to be completely pain-free before embarking on balance training). Thanks for bringing to light this important aspect of injury prevention.

As an engineering student at the City College of CUNY thirty years ago, I put myself of commission for a solid week when I twisted my ankle in a pothole as I was running to make it to the next class. I haven’t had an ankle sprain since, especially since I started wearing 8-inch high boots year-round regardless of weather twenty years ago :)

Boots definitely make a big difference in ankle stability for me; they also make me feel just a lot more secure in how I walk. But I have to watch every sidewalk crack and curb, basically scanning in front of me and also below me, or I’m likely to slip, trip, or sprain. I’ve lost count of how many sprains I’ve had, as well as fractures (two or three). Probably three decades ago after my second injury, I became something like a magnet for holes in the street and sidewalk. My first two ankle injuries didn’t get any treatment whatsoever, and after that, my proprioception was definitely completely altered. I’m going to watch that video a few times and get on it. Every day.

My chiropractor put my ankles, feet and toes back in line and put arch supports in my shoes – no more ankle pain. My lower back pain is improved along with my TMJ.
Additionally, my arches are getting stronger after less than 2 months with the supports.

Thanks for this, it’s an eye-opener. I’ve always had balance issues, and now have Meniere’s Disease and guess what? Lots of ankle sprains, too. Mostly my left ankle, and my left ear is the one affected most by the Meniere’s.

I have been taking Tai Ji and somewhat innately practicing improving my balance to get through the kicking portion of the routine. (When you’re learning, you tend to have to hold positions, rather than moving on to the next form. Having to hold my leg up, particularly standing on my left leg, is difficult for balance and strength reasons.) I’m going to try this very simple method of balance training to see if it helps.

A lot of runners have found strength training in the form of minimalist shoes (or no shoes) to be helpful as well. Trying wearing racing flats for a 1-2M jog or running a few laps of a track barefoot once a week. Go slow and easy. Build up gradually.

As your strength and technique improves, you will feel a lot more stable and hopefully will be more resistant to injury…

Physical therapy after a complicated ankle fracture and sprain of my other ankle gave me back the strength I had lost. i strongly suggest getting a prescription for PT from the doctor. Balance training is part of what PT does, and you are supervised by an expert. Cuts down on falling while brushing teeth on one leg.

This is very interesting. I am also a chronic ankle sprainer, and have been told that I basically have no ligament strength left in one of my ankles. I also do yoga regularly and struggle disproportionately with standing balance postures compared to other postures (handstands are easier for me than many one-legged balance poses). I figured that it was because of my ankle sprains that I had bad balance, and not the other way around. i like the idea of focusing on doing more one-legged balancing to improve my proprioception. What I’m wondering is if a 6 or 10 week balancing regimen is enough to ‘permanently’ improve proprioception or if I would need to do such exercises regularly for the rest of my life?

Gretchen Reynolds responds: I checked with Dr. Patrick McKeon, one of the experts quoted in the story, for his advice about how long a person should practice balance training. This is what he had to say:

There is currently limited evidence regarding the dose of balance training that is essential for the reduction in risk of ankle sprains. I recommend sticking with balance training for at least four weeks, performing it at least 3 days a week. You can first try it for a couple of minutes a day and build up to a few minutes to a half an hour. Most importantly, stick with an exercise until you improve (i.e. time yourself to see how long you can balance, count the times you touch down, measure the distance you can hop, etc.) As you track your progression and as you improve, make it more challenging by closing your eyes, standing on uneven surfaces (such as couch cushions at home or foam pads) or change the direction or distance that you hop and reach. With regards to a few comments about whether balance training should be continued throughout the rest of your life, there is evidence to support that as people age, balance becomes more impaired.

Although there is limited research on doing balance exercises for the rest of your life to help to prevent episodes of recurrent ankle sprains, there is plenty of evidence that suggests that balance training improves function associated with aging. Balance training is definitely beneficial for reducing disability associated with ankle sprains and also helps to fend off the balance deficits associated with aging. So doing it in the long term should be beneficial (If you don’t use it, you lose it). Most importantly, before you undertake any type of balance training, check with your physician, physical therapist, or athletic trainer to ensure that it’s appropriate for you and get their recommendations on how intense you should start.

I broke my ankle two+ months ago. I’m walking again, but of course, I tend to be wobbly to say the least. Would such an exercise be valuable for me, too? The physiotherapist has me doing various things as it is, but the exercise you describe here is not specifically one of them. Suggestions?

I severely sprained my ankle at 17 – something I’ve had to explain to surprised passers-by after I’ve hit the sidewalk, more times than I care to mention. The repeated falls have bruised both my knees and my ego.

James Garrick’s book (with Peter Radetsky), Peak Condition, has the DEFINITIVE chap. on “RICE”, explaining that wrapping an ankle after a sprain has to be done in a very special way (the book details this superbly). I am an elderly (!) tennis player/woman now, but have used this tech. on my son and my tennis team members, with results that got plaudits from emergency rooms, after sprains.
I’ve also been standing on one ft brushing teeth for quite a while (2 yrs?), most of the time, tho I simply can’t do it for a SECOND with eyes closed. (Is that scary? I’d like to know). It’s a cinchy way to do it. My elec. toothbrush even does the timing.
But I want to strongly recommend PEAK CONDITION, sadly out of print, but available at used bk stores if you are lucky. I bought up all the ones Powell’s in Portland, OR, had, some years ago, and gave them as gleefully-received gifts. I reread this book AS I DO NONE OTHER. It is amazing.

I took a modern dance class in college (easy humanities credit for an engineer!) but it really was eye-opening, and changed the way I carry myself. I was never much aware of my posture or stride, but now I can’t walk down the street without observing all the bad habits of others. Why do you waddle? Don’t slouch! Toes forward, not pointed out!
Who hasn’t tried to walk, balancing a book on one’s head? Maybe there is something to that trick after all!

My ankles are the bane of my existence. I had a terrible sprain (after literally dozens of sprains from childhood on) a few years ago that’s never quite healed. I have an insert for the injured ankle (a Godsend) but my mileage hasn’t ever been the same. Maybe I’ll embark on this and try to improve my balance.

What happens when you develop arthritis in your ankle?
Does the balancing therapy work for this as well?
I’ve been to a number of orthopedic surgeons- all anyone can offer me is to fuse my bones -no more pain, but a permanent limp.
No thanks, I think I’ll wait until someone develops ankle replacement surgery!

Gretchen Reynolds responds:

Hi Cheryl — Ankle replacement surgery actually exists now, although it’s not nearly as common as knee or hip replacement. You can learn more about the surgery and about whether it might be right for you on the website of the American Academy of Orthopedic Surgeons: http://www.aaos.org.